Complaint Investigation Report

reviewed the Trust Account/P & I Ledgers (March 2023 & October 2023), Incident Reports (02/21/23 – 03/01/23), Staff In-service Training Records, Monthly Menu (October 2023), Facility Staff (S1-S5) and Residents (R9-R12) files, Facility Staff and Residents' rosters (dated 02/23/22 & 10/06/23). LPA/RA toured the facility's physical plant: memory care unit, medication room, and commercial-size kitchen. LPA/RA observed the security monitors and camera system and delayed egress doors.

Regarding Allegation #1 : this investigation revealed that the facility is a vendor of the Harbor Regional Center (HRC) and participant of the Assisted-Living Waiver program. Residents who require 24/7 level of care reside in the facility’s secured unit on the 2 nd floor that requires a key-card system. Interviews conducted of seven (7) staff corroborated that the facility does not have residents with a prohibited health condition. Executive Director stated that whenever a resident requires a higher level of care, facility staff will call 9-1-1 or non-emergency ambulance. If the facility receives a call regarding accepting/returning a resident with a prohibited health condition, they are advised that the facility is not a medical facility. Interviews conducted of eight (8) residents, corroborated that they did not have a prohibited health condition nor had they known of residents living in the facility with a prohibited health condition.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of LEVEL OF CARE: Staff are allowing residents with prohibited health conditions to reside in the facility is found to be UNSUBSTANTIATED.

Regarding Allegation #2 : this investigation revealed based on interviews conducted of seven (7) facility staff who corroborated that whenever a resident has sustained a skin tear, the med techs will provide first-aid. Interviews conducted of eight (8) residents corroborated that they are provided with first aid by the med techs whenever they have sustained a skin tear. LPA/RA reviewed facility staff in-service training record on the topic of How to Manage Elderly Skin, Skin Integrity, and First Aid.

Based on the evidence gathered, interviews conducted, and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF SUPERVISION: Staff are not preventing residents from sustaining skin tears while in care is found to be UNSUBSTANTIATED.

Regarding Allegation #3 : this investigation revealed based on interviews conducted of seven (7) facility staff members corroborated that often a resident cannot hear so facility staff often has to raise their voice in